MEDICAL INFORMATION FORM
(Information provided will be used for emergency situations only.)
Name: ____________________________ Birth Date: ______________
Street Address: _____________________________________________
City: ________________________ State: __________ Zip: __________
Gender: M F
Phone: (_______)__________________________
Please list any medical conditions that may affect participation:
___________________________________________________________
Please list any medications that the youth will be bringing to the volleyball
camp: ______________________________________________________
Can first aid such as ice packs and band aids be administered?:
__________________________
Can over the counter medicines such as Tylenol, antacid or triple antibiotic
be administered?: _____________________________________________
Please list any known allergies: __________________________________
PARENTAL CONSENT
To Whom It May Concern:
The undersigned does hereby give permission for our (my) chi
ld_____________________________to attend and participate in the volleyball camp at Concordia University in St. Paul, Minnesota from July 16
through 18, 2012. We (I) authorize an adult, in whose care the minor has
been entrusted, to consent to any X-ray examination, anesthetic, medical,
surgical or dental diagnosis or treatment, and hospital care, to be rendered
to the minor under the general or special supervision and on the advice of
any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis
or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses
incurred in connection with such medical and dental services rendered to the
aforementioned child pursuant to this authorization. Should it be necessary
for our (my) child to return home due to medical reasons or otherwise, the
undersigned shall assume all transportation costs. The undersigned does
also hereby give permission for our(my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Concordia University. I give
permission for any pictures or videos taken during the conference to be used
at the discretion of Concordia University, the students, faculty, staff, or other
representatives. I release and forever discharge Concordia University, their
agents and servants, successors and assigns, directors, trustees, officers,
employees, and other representatives against loss from any and all present
or future claims, demands or actions in law or in equity that may hereafter
be made or brought by me or my child, by anyone on behalf of me or my
child, or by anyone else on their own behalf for damages or any other legal
or equitable remedy on account of any injury, illness, physical condition, inconvenience, or loss sustained by my child during the planned activities for
which my child is registering to participate.
Hospital Insurance: Yes No
Insurance company: ___________________________________________
Policy number: ________________________________________________
Emergency Contacts: __________________________________________
Emergency phone numbers: _____________________________________
Camp Description
and Philosophy
Concordia University Volleyball Camps are
designed to involve youth with the sport and
team building concepts of volleyball. The
Team Camp is geared towards athletes of
all levels. The emphasis of this camp is
placed on team concepts and development.
Concordia University
Volleyball Presents....
Meet the Camp
Coaching Staff
Brady Starkey is entering his 10th
season at the helm of the Golden
Bear program. In his tenure as head
coach, Starkey has amassed a record
of 306 wins and 26 losses. Along with
5-straight NCAA Championships, Starkey has been named the AVCA National Coach of the Year three times (2007, 2010, 2011),
Central Region Coach of the Year (7 times) and NSIC
Coach of the Year (5 times). Starkey has also coached
35 AVCA All-Americans during his time at CU. He is
NCAA Volleyball’s active leader in career winning percentage (92%) spanning all divisions (I, II, III).
2012 Team Camp
George Padjen enters his 10th year
as the Golden Bears assistant coach.
Padjen is involved in all aspects of
coaching for the volleyball program
and has been an integral part of the
programs success. Prior to joining
the Concordia staff, George was the
assistant volleyball coach at St. Scholastica in Duluth, Minn. He also adds many years of experience
coaching Junior Olympics and summer camps.
Parent/Legal Guardian signature:
_______________________________________________
Date: ________________________
*** this form must be completed and returned with registration***
In addition to coaches Starkey and Padjen, many
current and past members of the tradition-rich
Concordia Volleyball team will be assisting at this
camp, too!
July 21-22
Gangelhoff Center
St. Paul, MN
Why Concordia Camps?
2012 Concordia
Team Camp
5-TIME NCAA CHAMPION PROGRAM
2007 | 2008 | 2009 | 2010 | 2011
JULY 21-22, 2012
GRADES 7 - 12
9-Straight NSIC Championships
9-Straight NCAA Sweet 16 appearances
7 total NCAA Elite Eight appearances
NCAA record 75-match win streak (2008-10)
30-match NCAA Tournament win streak (active)
Since making the transition to NCAA Division II athletics in 1999, the volleyball program has put Concordia University on the map.
Our goal at CU Volleyball General Skills Camp is to
bring this winning philosophy to you.
We feel our emphasis on individual training distinguishes us from all other camps. Our coaches bring
with them years of playing and coaching experience
that allows them to understand what is important to
athletes: teaching, challenging them … and creating
a sense of excitement for volleyball.
You will be able to sense this excitement in every
aspect of our camp.
COST: $120 PER PLAYER
(cost includes admission to 4, 3-hour sessions!)
This camp is created for those athletes interested in
learning team concepts.
Registration
Name ___________________________________
Address __________________________________
City _____________________________________
State _______________________ Zip __________
Phone ________________________
Email ____________________________________
Learn from National Champion players and coaches to
train your game “The CU Way!”
* Skill training session: “How CU does it”
* Skills learned: communication, armswing,
blocking, defense, transition and more!
* Team training session
* Skills learned: communication,
blocking/defense, serve receive, covering, etc.
School ___________________________
Grade in Fall _______
___Team Camp ($120 per player)
T-Shirt Size (circle one) S M L XL
Parent Signature ____________________________
Date ____________________________________
In Concordia’s Team Camp, each team participates
in 4, 3-hour sessions (2 each day). Each session on
Saturday begins with 45-minutes of skill and training
practice with over 2-hours of competition. On Sunday,
the session is devoted entirely to competition.
All campers receive official Concordia Camp t-shirts!
Registration is capped at the first 80 campers,
complete your forms TODAY to reserve a spot!
Please Make Checks payable to:
Concordia University Volleyball
Medical Information Form must be
completed and returned with registration
Mail completed forms to:
Concordia University Volleyball
Attn: George Padjen
275 Syndicate St. N
St. Paul, MN 55104
Please contact George Padjen with any questions:
Phone: 612.327.6355 | padjen@csp.edu
5-time NCAA Champs
2007 | 2008 | 2009 | 2010 | 2011